RE: summary lists for hospital based outpatient rehab

[Guest guest]

We use a universal " intake form " in our outpatient settings - that

includes the info reqd and also reason for visit etc. It requires

therapist sign off to show it has been reviewed - we also put the med

reconciliation piece on it - if we are potentially doing ionto/ phono.

We use this form also to screen the potential for a lingering Home

Health situation where we need to clear that for payment prior to

initiating OP care. We are currently asking our outpatient therapists

(they are on paper) to enter allergies into our EHR but this is really a

challenge to enforce when they are doing so many other " check points "

The theory being we could be the first point of contact - and if we

identify an allergy - or retrieve the first comprehensive list of meds -

that we should share them with the EHR so they would be available should

the patient end up in the ER. The patient completes the Intake Form

at registration.

Laurie

Sr. Director

________________________________

From: PTManager [mailto:PTManager ] On

Behalf Of Eileen Casey

Sent: Tuesday, April 12, 2011 2:52 PM

To: PTManager

Subject: summary lists for hospital based outpatient rehab

Good Afternoon,

On a recent JCAHO survey we were cited for not having a " summary list "

for each outpatient. Our initial evaluation form has documented PMH/PSH,

medications, allergies that is completed on the first visit however our

surveyor did not agree that this is a " summary list " .

As we are a small rural hospital we do not have a full EMR so a summary

list that is " readily available to all practitioners and updated

whenever there is a change in diagnosis, medications or allergies and

whenever a procedure is performed " per JCAHO is not in place.

Has anyone else dealt with this situation? Any suggestions?

Eileen Casey, PT

Director of Rehab Services

Brattleboro Memorial Hospital

17 Belmont Ave

Brattleboro, VT 05301

ecasey@... <mailto:ecasey%40bmhvt.org> <mailto:ecasey@...

<mailto:ecasey%40bmhvt.org> >

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